Deficiencies (last 4 years)
Deficiencies (over 4 years)
15.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
84 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights regarding this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individual rights to access and amend information, and legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
The inspection was conducted in response to a complaint (Complaint # NJ00182622) to assess compliance with regulatory requirements.
Complaint Details
Complaint # NJ00182622 was investigated and the facility was found to be in substantial compliance; no deficiencies were cited.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, and the New Jersey Administrative Code, Chapter 8:39, based on this complaint visit.
Report Facts
Census: 84
Inspection Report
Routine
Census: 84
Capacity: 112
Deficiencies: 7
Date: Dec 12, 2024
Visit Reason
A routine recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident rights, safe/comfortable environment, activities, infection control, facility assessment, fire safety, and other regulatory requirements. Corrective actions and plans of correction were documented with completion dates.
Deficiencies (7)
Failure to ensure residents' rights to dignity and care in a manner promoting their individuality and equal access to quality care.
Failure to provide a safe, clean, comfortable, and homelike environment.
Failure to provide activities meeting interests and needs of residents.
Failure to establish and maintain an infection prevention and control program.
Failure to ensure physician visits are timely and documented.
Failure to maintain safe environment including fire safety and means of egress.
Failure to maintain safe oxygen cylinder storage and labeling.
Report Facts
Census: 84
Total licensed beds: 112
Deficiency completion dates: Dec 25, 2024
Inspection Report
Routine
Capacity: 112
Deficiencies: 11
Date: Dec 12, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, infection control, and administrative requirements.
Findings
The facility was found deficient in multiple areas including failure to provide dignified meal service and assistance, inadequate nail care, failure to provide meaningful activities and qualified activity director, inadequate supervision to prevent falls, inconsistent smoking policies and practices, failure to ensure timely physician visits, improper respiratory equipment storage, incomplete facility-wide assessments, failure to inform residents about arbitration agreements, infection control lapses including hand hygiene and PPE use, and unsafe environmental conditions such as sharp corner guards.
Deficiencies (11)
Failed to ensure meals were consistently provided in a dignified and homelike manner and provide resident meal assistance in a dignified manner.
Failed to provide nail care to residents unable to carry out activities of daily living.
Failed to provide activities to meet all residents' needs and conduct ongoing activity assessments.
Failed to ensure the activities program was directed by a qualified professional.
Failed to ensure adequate supervision to prevent falls and implement appropriate fall interventions for a high-risk resident.
Failed to ensure respiratory equipment was stored and dated in accordance with professional standards.
Failed to ensure residents and their doctors met face-to-face at all required visits and timely documentation of physician visits.
Failed to conduct and document a facility-wide assessment addressing needs of residents who smoked and Asian American populations including policies, services, and staff competencies.
Failed to inform residents or representatives about arbitration agreements and their right to refuse prior to signing.
Failed to provide and implement an infection prevention and control program including proper signage for Enhanced Barrier Precautions, hand hygiene, glove use, ice container sanitation, and cell phone hygiene.
Failed to ensure nursing home area was safe and comfortable by not providing protective endcaps to sharp corner guards.
Report Facts
Facility licensed capacity: 112
Fall incidents: 11
Residents on smoking list: 14
Residents affected by Enhanced Barrier Precautions: 8
Residents affected by arbitration agreement issue: 9
Residents affected by infection control issues: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Observed using cell phone during resident feeding and acknowledged failure to perform hand hygiene. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding smoking procedures and respiratory equipment storage. |
| LPN/UM | Licensed Practical Nurse / Unit Manager | Interviewed regarding nursing care expectations and respiratory equipment storage. |
| VPRN | Vice President of Clinical Services Registered Nurse | Provided information on arbitration agreements and fall incident reports. |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding smoking policy, arbitration agreements, and exit conference. |
| DON | Director of Nursing | Participated in interviews and exit conference regarding multiple deficiencies. |
| Regional DON | Regional Director of Nursing | Participated in interviews and exit conference regarding multiple deficiencies. |
| OT | Occupational Therapist | Observed wearing gloves improperly and interacting with multiple residents. |
| CNA #1 | Certified Nursing Assistant | Interviewed about falls and smoking procedures. |
| CNA #3 | Certified Nursing Assistant | Interviewed about smoking procedures and PPE. |
| AD | Activities Director | Interviewed regarding activities program and assessments. |
| SC/LCNA | Staffing Coordinator/Lead Certified Nursing Assistant | Stated she would be the new Activities Director but lacked qualifications. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
Annual inspection survey of Rose Mountain Care Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 91
Capacity: 112
Deficiencies: 15
Date: Sep 28, 2023
Visit Reason
A routine recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements but had deficiencies related to resident dignity, environment safety, grievance procedures, staff credentialing, care planning, infection control, staffing, food and diet, resident records, and other regulatory requirements. Corrective actions and plans of correction were documented.
Deficiencies (15)
Failure to treat residents with respect and dignity, including knocking on doors before entering and addressing residents appropriately.
Failure to maintain a safe, clean, comfortable, and homelike environment, including issues with roach activity and cleanliness.
Failure to maintain an effective grievance policy and process consistent with facility policy.
Failure to ensure all employees have current and verified credentials prior to hire.
Failure to ensure all grievances are entered on the grievance log and addressed timely.
Failure to ensure all residents have comprehensive care plans developed and updated timely.
Failure to ensure all discharged residents have a discharge summary completed and available.
Failure to provide adequate staffing levels to meet resident needs, including deficient CNA staffing on multiple shifts.
Failure to maintain accurate posted nurse staffing data and ensure payroll time clock data is accurate.
Failure to ensure all residents receive appropriate dietary preferences and nutritional care.
Failure to maintain complete and accurate resident medical records, including physician orders and documentation.
Failure to ensure all employees receive required physical exams and TB testing prior to hire.
Failure to ensure all employees receive required annual training, including behavioral health and infection control.
Failure to ensure all residents receive required immunizations and education.
Failure to maintain safe fire safety measures including self-closing fire doors and fire-rated door labels.
Report Facts
Census: 91
Total Capacity: 112
Sample Size: 19
Deficiency Count: 15
Staffing Deficiency: 14
Staffing Deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources Director | Human Resources Director | Named in credentialing and hiring deficiencies |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed regarding resident care and staffing |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staffing, grievances, and care planning |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Interviewed regarding grievances, staffing, and facility policies |
| Activities Director | Activities Director | Responsible for auditing resident dietary preferences |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding food service and resident dietary issues |
| Human Resource Director | Human Resource Director (HRD) | Interviewed regarding staffing and employee records |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 3
Date: Sep 28, 2023
Visit Reason
The inspection was conducted based on complaints alleging environmental cleanliness issues, resident abuse allegations, grievance handling deficiencies, and failure to timely report abuse incidents.
Complaint Details
The complaint investigation was triggered by multiple allegations including environmental cleanliness concerns, staff-to-resident abuse allegations involving Residents #56, #10, #13, #82, and #143, and failure to properly document grievances and report abuse incidents. Some abuse allegations were found unsubstantiated after investigation.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, with multiple areas showing dust, dirt, broken fixtures, and pest control issues. The facility failed to properly document and track grievances and did not timely report allegations of abuse to the state agency. Several abuse allegations were investigated and found unsubstantiated, but the reporting and documentation processes were inadequate.
Deficiencies (3)
Failure to provide a safe, clean, comfortable, and homelike environment with dust accumulation, broken tissue holders, and pest activity.
Failure to ensure residents' right to voice grievances without discrimination or reprisal and failure to maintain proper grievance documentation and tracking.
Failure to timely report suspected abuse to the New Jersey Department of Health as required by regulations.
Report Facts
Residents present in dining area: 16
Facility staff assisting residents: 5
Number of residents reviewed for environmental concerns: 3
Number of residents reviewed for grievance documentation: 5
Number of investigations of reportable incidents reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding environmental concerns, grievance process, and abuse reporting |
| DON | Director of Nursing | Interviewed regarding environmental concerns, grievance process, and abuse reporting |
| ADON | Assistant Director of Nursing | Interviewed regarding abuse allegation reporting and investigation |
| MDSC/RN | MDS Coordinator/Registered Nurse | Interviewed regarding dining area cleanliness |
| HD | Housekeeping Director | Interviewed regarding laundry area cleanliness and housekeeping practices |
| LPN | Licensed Practical Nurse | Interviewed regarding skin assessment procedures |
Inspection Report
Routine
Census: 91
Deficiencies: 16
Date: Sep 28, 2023
Visit Reason
The inspection was a routine survey to assess compliance with state and federal regulations regarding resident care, facility environment, staffing, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including resident dignity, safe and clean environment, grievance handling, staff license verification, timely reporting of abuse, care planning, physician documentation, dialysis care, dietary preferences, staffing levels, and mandatory staff training.
Deficiencies (16)
Failed to treat residents with respect and dignity, including staff entering rooms without knocking.
Failed to provide a safe, clean, comfortable, and homelike environment, including issues with dust, broken tissue holders, and pest control.
Failed to ensure grievance policy was consistently followed and grievances were properly documented and tracked.
Failed to verify licensed staff credentials prior to hire for six of nine reviewed employees.
Failed to timely report allegations of abuse to the state agency within required timeframes.
Failed to revise care plan to address discharge plan when resident communicated intent to discharge.
Failed to obtain physician order for discharge and complete discharge summary for residents transferred to another facility.
Failed to follow physician orders for consultation and ensure physician documented recapitulation of resident's stay and progress notes.
Failed to provide communication device for resident with language barrier and maintain up-to-date activity calendars in resident's preferred language.
Failed to monitor residents returning from dialysis for access site and vital signs and complete dialysis communication records.
Failed to provide sufficient nursing staff to meet residents' needs and maintain required staffing ratios.
Failed to post accurate and up-to-date nurse staffing information daily.
Failed to ensure resident dietary preferences were identified and implemented, including appropriate hours of sleep snacks.
Failed to store foods properly and maintain sanitation to prevent foodborne illness.
Failed to maintain complete and accurate medical records for a resident receiving hospice care.
Failed to provide mandatory behavioral health training for certified nursing assistants.
Report Facts
Residents census: 91
Staffing deficiency days: 14
Staffing deficiency days: 1
CNA to resident ratio: 1
CNA to resident ratio: 1
CNA to resident ratio: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Acknowledged entering room without knocking and apologized | |
| Licensed Nursing Home Administrator (LNHA) | Discussed grievance process and staffing concerns | |
| Director of Nursing (DON) | Discussed grievance process, staffing, and care plan issues | |
| Assistant Director of Nursing (ADON) | Discussed grievance process and immunization surveillance | |
| Human Resource Director (HRD) | Discussed license verification and payroll time clock issues | |
| Food Service Director (FSD) | Discussed dietary preferences and food storage | |
| Recreation Director (RD) | Discussed activities calendar and communication with residents | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about staffing and assignments | |
| Certified Nursing Assistant (CNA) #3 | Missing behavioral health training documentation | |
| Certified Nursing Assistant (CNA) #5 | Missing behavioral health training documentation |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The inspection was conducted as a complaint survey based on allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Complaint Details
Complaint # NJ00151843, NJ00162232. The complaint investigation revealed failure to report an injury of unknown origin for Resident #2, which was not reported to administration as required. The injury was later determined to be due to the resident resting on the dining table, not abuse.
Findings
The facility was found not in compliance with requirements related to reporting alleged violations of abuse or injuries of unknown origin. Specifically, staff failed to immediately report an injury of unknown origin for one resident, Resident #2, as required by facility policy and regulations.
Deficiencies (1)
Failure to immediately report an injury of unknown origin to facility administration for Resident #2 as required by policy and regulations.
Report Facts
Sample Size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in failure to report injury of unknown origin for Resident #2 |
| Director of Nursing | DON | Interviewed regarding reporting procedures and investigation |
| Assistant Director of Nurses | ADON | Conducted audits and interviewed regarding reporting and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an injury of unknown origin for Resident #2 as required by policy.
Complaint Details
The complaint investigation found that the facility staff did not report an injury of unknown origin (yellow discoloration on Resident #2's forehead) to administration as required. The discoloration was due to the resident resting her forehead on the dining table. The facility policy mandates immediate reporting of suspected abuse or injuries of unknown source, which was not followed.
Findings
The facility staff failed to immediately report a yellow discoloration injury of unknown origin on Resident #2's forehead to administration. The discoloration was observed by the surveyor but was not reported by nursing staff, who believed it was not an injury of unknown origin due to the resident's behavior. The administration and Director of Nursing were unaware of the discoloration until the survey. The facility's policy requires immediate reporting of such injuries, which was not followed.
Deficiencies (1)
Failure to timely report suspected abuse or injury of unknown origin to facility administration as required by policy.
Report Facts
Residents Affected: 3
Residents Affected: Few
Discoloration size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Signed weekly shower skin assessment and explained non-reporting of discoloration |
| Director of Nursing | Director of Nursing | Clarified skin assessment documentation process and acknowledged reporting failure |
| Administrator | Administrator | Completed investigation summary and confirmed unawareness of discoloration |
| ADON | Assistant Director of Nursing | Stated that CNAs and nurses should report any skin alterations |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Aug 9, 2021
Visit Reason
The inspection visit was conducted in response to complaint #NJ 146287 to assess compliance with regulatory requirements.
Complaint Details
Complaint # NJ 146287 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample size: 3
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 2
Date: Jun 23, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, focusing on staffing ratios and nurse aide certification verification.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by New Jersey state law and did not have a system in place to consistently verify nurse aide credentials upon hire.
Deficiencies (2)
Failure to maintain minimum direct care staff-to-resident ratios as required by New Jersey state law.
Failure to have a system in place to ensure nurse aide credentials were consistently verified upon hire.
Report Facts
Census: 84
Certified Nursing Aides on 7:00 AM - 3:00 PM shift: 7
Certified Nursing Aides on 3:00 PM - 11:00 PM shift: 5
Certified Nursing Aides on 11:00 PM - 7:00 AM shift: 4
Residents per CNA on 7:00 AM - 3:00 PM shift: 12
Residents per CNA on 3:00 PM - 11:00 PM shift: 16.8
Residents per CNA on 11:00 PM - 7:00 AM shift: 21
Inspection Report
Routine
Deficiencies: 7
Date: Jun 23, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, abuse reporting, medication administration, care for contractures, catheter care, behavioral health services, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to timely report and investigate abuse allegations, improper medication administration practices, inadequate care planning and intervention for contractures, inconsistent suprapubic catheter site care, failure to provide urgent psychiatric consultation for suicidal ideation, and lapses in infection prevention and control practices including hand hygiene and PPE use.
Deficiencies (7)
Failure to treat residents with respect and dignity, including inappropriate handling of residents and their personal possessions.
Failure to timely report an allegation of abuse to the New Jersey Department of Health and failure to follow facility policy for abuse reporting.
Failure to verify or dispose of unlabeled pre-filled insulin syringes, violating professional standards of medication administration.
Failure to evaluate and implement appropriate care plan interventions for a resident's right hand contractures.
Failure to provide consistent suprapubic catheter site care to prevent infection.
Failure to provide an urgent psychiatric consultation for a resident expressing suicidal ideation.
Failure to adhere to infection control practices including hand hygiene, disinfection of multi-use equipment, and proper donning of PPE prior to entering rooms of residents on transmission-based precautions.
Report Facts
Residents reviewed for dignity: 24
Residents affected: 3
Residents reviewed for abuse: 2
Residents affected: 1
Nurses reviewed for medication administration: 2
Residents reviewed for range of motion: 1
Residents reviewed for catheter care: 1
Residents reviewed for mood/behavior: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including abuse investigation, medication administration, catheter care, psychiatric consult, and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in findings related to abuse reporting, psychiatric consult, and infection control |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Named in medication administration and infection control deficiencies |
| Registered Nurse | Registered Nurse (RN) | Named in medication administration and infection control deficiencies |
| Physical Therapy Assistant | Physical Therapy Assistant (PTA) | Named in dignity deficiency related to resident transport |
| Social Worker | Social Worker (SW) | Named in dignity deficiency related to removal of resident's calendar |
| Occupational Therapist | Occupational Therapist (OT) | Named in care planning for contracture deficiency |
| Facility Interpreter | Interpreter | Named in psychiatric consult deficiency |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: May 14, 2021
Visit Reason
The inspection visit was conducted in response to a complaint identified as NJ140556.
Complaint Details
Complaint number NJ140556 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample Size: 3
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